The Russian invasion of Ukraine began on February 24, 2022 with Russian President Vladimir Putin announcing a special military operation seeking “demilitarisation and denazification” of Ukraine. He alluded that his war on a sovereign country was meant to contain the remnants of Nazism there.
The Russian invasion will complete a year this week with disastrous consequences for the health and well-being of a large number of people. It also raises several disturbing questions on the inability of global powers to stop aggression on an independent nation. The timing of the war, the excuses used by Russia, the international community’s response, and the inability of the UN Security Council to broker peace raise questions on the role of multilateralism.
There hasn’t been an effective global response to the targeting of the health systems and civilians, an exodus of refugees, casualties on both sides, and the humanitarian crisis that followed the Russian invasion of Ukraine. In early 2022, the world had struggled to cope with the consequences of the covid-19 pandemic.
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UN secretary general António Guterres’s call for a cease-fire did not get any attention from the warring parties. The UN General Assembly and the Security Council did not develop a strategy to solve the crisis. The Security Council was rendered ineffectual by its veto system.
Some western countries have tried to punish Moscow’s invasion of Ukraine through the Institute of International Bankers. These include restrictions on Russia’s export of oil and gas, restrictions on its largest banks, and curbs on the sale of technology to its military. These did not have a major impact on the Russian economy or its ability to finance the war in Ukraine.
Russian invasion of Ukraine and global health
The impact of the Russian invasion of Ukraine needs particular attention from Global health practitioners and students. There is a large amount of data on war-related morbidity and mortality and the impact of war on healthcare facilities and healthcare providers. The War and conflict have far-reaching public health consequences including reduced access to healthcare, displacement, disruption of education, psychological trauma, infrastructure destruction, and exploitation of the vulnerable including women, children, the elderly, and the disabled.
The magnitude of civilian suffering, consequences of abrupt population displacement, and parameters of humanitarian response in the war zone also call for closer examination by the global community. According to the UN Refugee Agency, nearly 8 million Ukrainian refugees are in other European countries. The civilian casualties since the conflict began include 7,068 deaths and 11,415 injured. In addition, approximately 5.9 million people have been internally displaced within Ukraine. Infrastructure damage is currently estimated at $100 billion.
Russian President Vladimir Putin had ordered a unilateral 36-hour cease fire for Russian troops to observe Christmas. Russian Christians celebrate Christmas on January 7. However, that gesture did not create any long-term solution.
Ukrainian President Volodymyr Zelensky responded with derision in his nightly address, questioning Mr Putin’s motives. He said Russia wanted “to use Christmas as a cover” to stop Ukrainian advances, regroup and bring more troops up to the front. However, despite the UN General Assembly resolution that calls for Russia to pay war reparations to Ukraine, Putin is continuing to attack Ukraine.
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The UN General Assembly adopted a resolution recognising that the Russian Federation’s military offensive inside Ukraine and its humanitarian consequences are on a scale that the international community has not seen in Europe in many decades. The Assembly adopted draft resolution that recorded a vote of 140 in favour to 5 against (Eritrea, Russian Federation, Syria, Democratic People’s Republic of Korea, Belarus), with 38 abstentions. It was signalling the international community’s demand that Moscow immediately halt its hostilities against Ukraine so that the corollary humanitarian impact could be contained (UNGA 2022).
The global community is still watching the unfolding horror in disbelief. Furthermore, the war has crossed its tenth month. Putin’s disregard for and efforts to undermine the global multilateral agencies are also to be noted. For example, UN Security Council’s attempt to censure Russia was disregarded by Russia with the support of another veto power country, China. On the other hand, China may have a reason to support Russia in its war on Ukraine, as China is inclined to capture Taiwan forcefully.
The Russian invasion of Ukraine is another example of the catastrophic health-related consequences of war. The Ukrainian war is far more destructive than Russia’s previous destruction of Chechnya and bombardment of health facilities and neighbouring populations in Syria.
Attack on health systems
According to the WHO representative in Ukraine, Jarno Habicht, Russia has attacked over 700 healthcare facilities since it invaded Ukraine on February 24 last year. These assaults on healthcare, he said, have adversely affected facilities, supplies, and transport, injuring and killing healthcare workers and patients. Approximately 100 healthcare workers died from the attacks, and 129 were injured.
The Office of the UN High Commissioner for Human Rights (OHCHR) recorded 15,246 civilian casualties in Ukraine – 6,114 killed and 9,132 injured between February 24 and October 2, 2022. Russian war on Ukraine has underscored the long-standing issue of attacks on hospitals, medical personnel, and civilian populations during wars.
The health impact of the Russian invasion of Ukraine is severe and complex. Communicable diseases are more easily transmitted in crowded living conditions with decreased access to safe water and food, compromised sanitation and hygiene, inadequate medical care, and missed immunisations. The war has increased the demand for health care while reducing the health system’s ability to provide services, particularly in areas of active conflict.
Another significant unmet healthcare need is appropriate training to deal with the unique effects of war – trauma surgery, mass casualties, burns and chemical exposure. During the war, civilians are especially at risk for diarrheal diseases like cholera and respiratory disorders like measles, Covid-19, and tuberculosis. In addition, antimicrobial resistance often increases during the war. The ongoing war’s mental health impact has been unprecedented in Europe since the end of the Second World War. Almost 10 million people at present are potentially at risk of mental disorders such as acute stress, anxiety, depression, substance use and post-traumatic stress disorder (PTSD).
Globally, it is estimated that about one in five people in conflict settings have a mental health condition. The situation in Ukraine is no exception. An estimated 22% of the population currently living in areas affected by conflict will likely have some form of mental health challenge at any time during the next 10-year period, with one in 10 suffering from a moderate or severe condition like depression with suicidal behaviour or psychosis.
Ukraine suffers from low immunisation rates for several infectious diseases. The national Covid-19 vaccination rate for one dose is estimated to be 36 per cent. Routine immunisation rates for measles are troublingly low and have been exacerbated by Covid-19-related disruptions – the national average is too low to prevent dangerous outbreaks. In 2018, Ukraine saw Europe’s most extensive measles outbreak since the vaccine became widely available. Moreover, an ongoing vaccine-deprived poliovirus outbreak makes the risk of increased polio transmission particularly alarming.
Eradicating polio has been a worldwide effort over many years. Polio is a highly infectious disease that predominantly affects children under five years of age, causing permanent paralysis (approximately 1 in 200 infections) or death (5-10% of those paralysed). Of the three strains of wild poliovirus (type 1, type 2 and type 3), wild poliovirus type 2 was eradicated in 1999, and wild poliovirus type 3 was eradicated in 2020. However, as of 2022, endemic wild poliovirus type 1 remains in Pakistan and Afghanistan.
Since October 2021, at least 22 cases of polio have been found in Ukrainian children, including two paralytic cases. A “catch-up” polio immunisation campaign, introduced by the Ukrainian Ministry of Health and the World Health Organization (WHO) in early February 2022, has now been suspended following the invasion.
Independent International Commission of Inquiry
Created by the mandate of the resolution adopted by the UN Human Rights Council, the Independent International Commission of Inquiry on Ukraine has found reasonable grounds to conclude that Russia has committed several war crimes. The Commission conducted investigations of war-related events in Kyiv, Chernihiv, Kharkiv, and Sumy regions of Ukraine. As a result, the Commission reported violations of human rights and violations of international humanitarian law. Furthermore, given the gravity of the identified violations, the Commission submitted a detailed written report to the United Nations General Assembly.
“The impact of these violations on Ukraine’s civilian population is enormous. Thousands of lives have been lost”. “The destruction of infrastructure is devastating,” said Commission Chair Erik Møse. Erik Møse is a former judge of the Europe Court of Human Rights, a former President of the International Criminal Tribunal for Rwanda, and a former judge of the Supreme Court of Norway. He is an expert in international human rights law and international criminal law.
The Commission documented attacks where explosives were used indiscriminately in populated areas under attack by Russian armed forces. The Commission also found that Russian armed forces attacked civilians attempting to flee. There are also examples of both parties to the armed conflict, although to different degrees, failing to protect civilians or civilian objects against the effects of attacks by locating military objects and forces within or near densely populated areas.
Ukrainian officials gather evidence and document sexual crimes, which are prevalent and devastating in times of war but often remain hidden under layers of shame, stigma and fear. “We found all types of cases of war crimes: rape, forced nudity, sexual torture” inflicted on men, women and children, said Anna Sosonska, deputy head of the department in the prosecutor general’s office responsible for investigating conflict-related sexual crimes. Ms Sosonska said a pattern to the crimes is emerging, “Now we see there is a line of war crimes in the Russian Army and among Russian commanders.”
The International Criminal Court (ICC) announced its jurisdiction over potential war crimes in Ukraine, relying on recent requests from its government. The 39 signatory states to the ‘Rome Statute’, which had created the ICC, also submitted formal proposals for the ICC’s jurisdiction. However, neither Russia nor Ukraine is a signatory state to the Roman statute. As a result, prosecution for war crimes and restitution will likely take years to complete.
The UN Security Council’s inability to end bilateral conflict is a warning sign. There is a need to explore ways to strengthen multilateral mechanisms, including UN reform of the veto system. The environmental impacts of the war in Ukraine are also severe. Many industrial plants are damaged or abandoned; wrecked sewage works gush their contents into rivers; damaged pipelines fill wetlands with oil and toxic military scrap is spread across the land. The global health community must be more vigilant in recognising and addressing the health impacts of war.
(The views expressed in the article are personal.)
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Dr Joe Thomas is Professor of Public Health, Institute of Health and Management, Victoria, Australia. Opinions are personal.